The NOSTRA model: Coherent estimation of infection sources in the case of possible nosocomial transmission.

Nosocomial, or hospital-acquired, infections are a key determinant of patient health in healthcare facilities, leading to longer stays and increased mortality. In addition to the direct effects on infected patients, the burden imposed by nosocomial infections impacts both staff and other patients by increasing the load on the healthcare system. The appropriate infection control response may differ depending on whether the infection was acquired in the hospital or the community. For example, nosocomial outbreaks may require ward closures to reduce the risk of onward transmission, whilst this may not be an appropriate response to repeated importations of infections from outside the facility. Unfortunately, it is often unclear whether an infection detected in a healthcare facility is nosocomial, as the time of infection is unobserved. Given this, there is a strong case for the development of models that can integrate multiple datasets available in hospitals to assess whether an infection detected in a hospital is nosocomial. When assessing nosocomiality, it is beneficial to take into account both whether the timing of infection is consistent with hospital acquisition and whether there are any likely candidates within the hospital who could have been the source of the infection. In this work, we developed a Bayesian model which jointly estimates whether a given infection detected in hospital is nosocomial and whether it came from a set of individuals identified as candidates by hospital staff. The model coherently integrates pathogen genetic information, the timings of epidemiological events, such as symptom onset, and location data on the infected patient and candidate infectors. We illustrated this model on a real hospital dataset showing both its output and how the impact of the different data sources on the assessed probabilities are contingent on what other data has been included in the model, and validated the calibration of the predictions against simulated data.